Tag Archives: performance improvement

All trauma centers verified by the American College of Surgeons (ACS) are required to classify trauma patient deaths into one of three categories: unanticipated mortality, mortality with opportunity for improvement, or mortality without opportunity for improvement. I’ve provided some details about each of those over the past several posts. But I do want to provide a little more detail for the much dreaded “unanticipated mortality.”

You may have noticed that unanticipated mortality does not seem to come in the same two flavors as the anticipated mortality: with and without opportunity for improvement. Why is this? Does this imply that all unanticipated mortalities have some opportunity or another? I actually used to think so.

But over time, I’ve changed my mind. It is true that the vast majority of unanticipated mortalities involve one, and many times, several opportunities that may improve the outcome for similar patients in the future. But I have personally seen at least two that did not.

How can this be, you say? Let me give you a far-fetched example. A healthy young male is involved in a car crash, sustaining fractures of a few ribs which are very painful. He is admitted for pain control, and is treated with your usual regimen of analgesics, mobilization, and pulmonary toilet. He admits to no significant medical or surgical history and is taking no medications. As he is sitting in his room waiting for his ride on the day of discharge, a small meteorite plunges through his window and strikes him in the head, killing him instantly.

So where’s the opportunity? Put meteorite shielding around your entire hospital? I think not. Don’t be ridiculous, you say, that’s not a realistic example. But what if, on the day of discharge, he stands up in his room and keels over in PEA arrest? An autopsy is performed, and a massive pulmonary embolism is identified. And let’s say that this patient somehow met your DVT prophylaxis criteria and he was receiving appropriate management per your practice guideline. And when you convey these findings to the family, they seem to recall a pattern of pulmonary embolism deaths and DVT complications in other family members. But nobody mentioned this to you during the history and physical exam. And you treated them exactly according to your protocol.

So what do you think now? Is there an opportunity? I still think not! But you must still pick apart every bit of the patient’s care, trying to identify anything that was not done according to plan or protocol that may have led to this (extremely) adverse outcome. But be aware that over your career as a trauma professional, you will likely run into one or more of these cases that are unanticipated but completely nonpreventable!

Note the subtle difference. The old name presumes you could have done something about it, which can lead to legal issues in some cases. The new one implies that death was unexpected, but does not presume that it could have been prevented. However, in most cases analysis shows that it could have.

Any unanticipated mortality should launch a full investigation from the trauma performance improvement program. In some cases, hospital quality may need to get involved. A root cause analysis may be indicated, depending on how many factors are involved. These cases must be discussed by the multidisciplinary trauma PI committee, at a minimum. It’s essential that everyone involved do their homework and become familiar with every aspect of care so that a meaningful analysis can occur at the meeting.

Trauma center reviewers will expect to see detailed documentation of the analysis in the PI committee minutes. And unless the death was a complete and unpreventable surprise there should be new protocols, policies and practice changes apparent. If these are not present, expect major reverification issues for your trauma center.

Is there an appropriate ratio of the three types of mortality? Obviously, there is a fair amount of variability. But after years of doing reviews, I can offer some guidelines. Here’s my 100:10:1 rule of thumb:

100 cases – mortality without opportunity for improvement

10 cases – mortality with opportunity for improvement

0-1 case – Unanticipated mortality

If your hospital’s numbers are outliers in any group, your clinical care and performance improvement program will get extra scrutiny. If all your cases are mortalities without OFI, then your PI process is too lax. This is a complex business, and there a many ways to improve our care. If your mortality with OFI cases are too frequent, your threshold for improvement may be set too low (see my previous post). If you have more than 1 or 2 unanticipated mortalities, then there may be some serious care quality issues.

Bottom line: When reviewing trauma mortality, be realistic but brutally honest. We learn from the mistakes we make. But by adhering to the process, you should never make the same mistake twice.

In my next post, I’ll provide some additional thoughts on unanticipated mortality.

Again, these sound somewhat similar but they are quite different. Potentially preventable death used to be applied to patients who had obvious care issues that had some potential to change outcome. But it also contained a number of patients discussed yesterday who had support withdrawn due to age or degree of injury. There was some nagging doubt that, it something else had been done, maybe they would have recovered. So several of the “potentially preventable” deaths in the old category have been moved to the “without opportunity for improvement” category.

Unfortunately, a larger group of patients from the nonpreventable death category have moved into the “with opportunity for improvement” category. This is actually a good thing, though. The mortality with OFI category looks at whether there were any care issues, regardless of whether support was eventually withdrawn.

Whereas the vast majority of deaths at any center should fall into the mortality without OFI category, a modest number will be classified as with OFI, about 10%. The actual number depends on how broadly or narrowly an opportunity for improvement is defined. If you consider a few areas of missing documentation on the trauma flow sheet an opportunity for improvement, then you’ll have a lot of deaths classified this way. Concentrate on issues that might have actually had an impact on the outcome. The key is to develop a set of criteria that is realistic and that work for you. If the number of deaths with OFI seems high, go back and look at those criteria and adjust them. You can still work out a system for improving trauma flow documentation without it changing every death in a trauma activation to one with an opportunity for improvement.

Tomorrow, I’ll discuss that most dreaded category, the unanticipated mortality.

This is the first in a series of four posts on mortality in trauma performance improvement.

The American College of Surgeons has a very specific naming convention for trauma deaths. This is an update of the system used prior to the current Optimal Resource Document (Orange Book), and has actually been revised since it was published. Of course, anytime you change something up, there will be some confusion. I’m going to compare old and new and give some of my thoughts on the nuances of the changes.

They seem similar, right? But the new name takes into account a growing phenomenon: elderly patients (or younger ones for that matter) who sustain injuries that might be survivable, but are devastating enough to cause the family to withdraw support. Technically, the deaths could be preventable to some degree, but the family did not wish to attempt it. The new system recognizes that it is an expected outcome due to patient or family choice.

There are several key points to handling mortality w/o OFI. First, if your center is providing great care, the majority of your deaths (about 90%) should be classified this way. Every one of them needs some degree of review, whether from just the trauma medical director and/or program manager or via the full trauma PI committee. However, your full PI committee needs to at least see a summary of the death if it’s not discussed in full.

How to decide on abbreviated review and report vs discussion by full committee? It depends on your trauma volume, and program preference. Higher volume centers do not usually have the luxury of discussing every case due to time constraints. Low volume centers may find value in reviewing these cases just to keep up on the detailed analysis and discussion required.

And how do you decide that there is no opportunity for improvement? The key is to look at the true clinical patient impact of the issue identified. If the issue is a minor clerical issue that has little impact on patient outcome or care, it can be classified as being without OFI. But it still needs to be reviewed, closed, and documented. If, however, future patients would benefit from having it closed, you must bump it up to the next category, mortality with opportunity for improvement.

In my next post, I’ll discuss the next type of trauma mortality, mortality with opportunity for improvement. I’ll follow up with the dreaded unanticipated mortality, and end with a bonus post on some nuances to that classification.

When a trauma patient is delivered to the emergency department but ends up in the morgue, two acronyms are typically thrown around. The first is DOA, which many people (think they) know about. This stands for “dead on arrival.” The other is DIE, which many are less familiar with. It stands for “died in ED,” and is less familiar to some.

What do they really mean, and why is the difference important? It can be quite confusing. All US trauma centers report data to the National Trauma Data Bank (NTDB). This database actually recognizes three types of ED death:

DOA. This is defined as declared dead on arrival with no or minimal resuscitative attempts. This is usually construed to mean no invasive procedures.

Died after failed resuscitation. This is a death within 15 minutes of arrival and does include invasive procedures.

DIE. These deaths occur in the ED but outside the 15 minutes in the previous category. Obviously, invasive procedures will have been performed.

The ACS Trauma Quality Improvement Program (TQIP) lumps the last two together when constructing reports for subscribing trauma centers. The objective is to exclude truly nonsalvageable patients from analysis to allow us to learn from patients who actually may have some chance of survival. Incorrectly classifying a DOA patient as DIE can significantly and adversely impact the mortality numbers for a center within TQIP.

Unfortunately, DOA is frequently misunderstood by those collecting data for their hospital’s trauma registry. What is an invasive procedure? Inserting an IV? Mechanical CPR? Intubation? REBOA?

The confusion typically occurs because the trauma team has a certain sequence of life-saving maneuver that they carry out based on ATLS principles. They must do this at the same time patient salvageability is being assessed. What denotes that transition from DOA to DIE?

Unfortunately, there is no literature that really dissects this. Here are my thoughts:

Mechanical CPR. This is commonplace to offload some of the work prehospital providers are doing during transport of the critical patient. DOA

IV insertion. This is a routine procedure and is something that could have been done in the prehospital setting. DOA

IO insertion. Same as IV insertion. DOA

Fluid administration. Again, this is a continuation of prehospital care. DOA

IV drug administration. This one is tricky. If one cycle of ACLS drugs are given while quickly assessing signs of life, DOA. Otherwise, DIE.

Intubation. This is pretty invasive, right? But again, EMS may have done this in the field. So if it is done while assessing signs of life and then the patient is quickly pronounced, DOA. Otherwise, DIE

Pelvic splint. Wrapping the pelvis should be routine in initial management of blunt traumatic arrest. DOA

Central line insertion. This is invasive and takes a little time. DIE

REBOA. Really? DIE

Bottom line: This is a difficult concept, and I’m sure some will disagree with my opinions above. I look at whether the cares provided are a continuation of prehospital support, are minimally invasive, AND ensure that they are only routinely applied while a rapid search for signs of life is in progress. Anything above and beyond this should be considered DIE.

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